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September 2, 2021

Targeted Probe and Educate (TPE) Process

Centers for Medicare & Medicaid Services (CMS) is resuming the Targeted Probe & Educate (TPE) process, effective September 1, 2021. Based on data analysis of claims payment, CGS will identify areas with the greatest risk of inappropriate program payment. Refer to the Medical Review Activity Log Web page for a list of review topics. Previous post payment service-specific reviews will be phased out.

Key Points

  • CGS selects providers for the TPE process based on the following:
    • Analysis of billing data indicating aberrancies that may suggest questionable billing practices; or
    • On targeted review and is transitioned to the TPE process based on error rate results; or
    • On service specific review error rate results.
  • CGS will mail a notification to those who have been selected for TPE review. The letter will outline the reason for selection and will provide an overview of the TPE process and contact information.
  • TPE consists of up to three rounds of review with up to 20-40 claims selected (pre or post payment) with each round. Subsequent rounds will begin 45-56 days after individual provider education is completed. Discontinuation of review may occur if appropriate improvement, and error rate below the target threshold is achieved during the review process.
  • Additional Documentation Request (ADR) is generated for each claim selected. CGS has 30 days (prepay) or 60 days (postpay) from the date documentation is received to review the documentation and make a payment decision.

    NOTE: No response to ADRs (denial reason 56900) counts as an error when calculating the error rate. CGS recommends using myCGS, our secure online web portal to submit documentation in response to medical review ADRs.
    • For additional information, refer to myCGS user manual.
    • If you are not already registered to use myCGS, refer to the enrollment instructions found under the introduction tab.
  • A letter with the review results will be mailed at the conclusion of each round. The letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part.
  • Providers with a moderate to high error rate will be offered an individualized education session where each claim found in error will be discussed and any questions will be answered. CGS also offers education sessions via webinar, web-based presentation, or traditional teleconferences. Other methods may also be available. Providers may also submit questions or request education via the Part A email box at
  • The TPE review process includes up to three rounds of a prepayment probe review with education. If there are continued high denials after three rounds, CGS will refer the provider to CMS for additional action, which may include additional rounds of TPE review, 100% prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. Discontinuation of review may occur with appropriate improvement, an error rate of <25% achieved during the review process.



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